WSES position paper on vascular emergency surgery
Pereira et al. World Journal of Emergency Surgery
WSES position paper on vascular emergency surgery
Bruno Monteiro T. Pereira 1
Osvaldo Chiara 0
Fabio Ramponi 3
Dieter G. Weber 2
Stefania Cimbanassi 0
Belinda De Simone 6
Korana Musicki 3
Guilherme Vieira Meirelles 1
Fausto Catena 6
Luca Ansaloni 5
Federico Coccolini 5
Massimo Sartelli 4
Salomone Di Saverio 7
Cino Bendinelli 2
Gustavo Pereira Fraga 1
0 Trauma Team, Ospedale Niguarda Milano , Milan , Italy
1 Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp) , Campinas, SP , Brazil
2 Department of Traumatology, John Hunter Hospital , Newcastle, NSW , Australia
3 Department of Cardiothoracic Surgery, John Hunter Hospital , Newcastle, NSW , Australia
4 Department of surgery, Macerata Hospital , Macerata , Italy
5 Department of general and emergency surgery, Papa Giovanni XIII Hospital , Bergamo , Italy
6 Department of Emergency and Trauma Surgery of the University Hospital of Parma , Parma , Italy
7 Department of surgery, Maggiore Hospital of Bologna , Bologna , Italy
Trauma, both blunt and penetrating, is extremely common worldwide, as trauma to major vessels. The management of these patients requires specialized surgical skills and techniques of the trauma surgeon. Furthermore few other surgical emergencies require immediate diagnosis and treatment like a ruptured abdominal aortic aneurysm (rAAA). Mortality of patients with a rAAA reaches 85 %, with more than half dying before reaching the hospital. These are acute events demanding immediate intervention to save life and limb and precluding any attempt at transfer or referral. It is the purpose of this position paper to discuss neck, chest, extremities and abdominal trauma, bringing to light recent evidence based data as well as expert opinions; besides, in this paper we present a review of the recent literature on rAAA and we discuss the rationale for transfer to referral center, the role of preoperative imaging and the pros and cons of Endoluminal repair of rAAA (REVAR) versus Open Repair (OR).
Trauma; Vascular injuries; Vascular control; Ruptured abdominal aorta aneurism; Vascular Trauma; Neck; Chest and Extremities
Trauma, both blunt and penetrating, is extremely
common worldwide. As a result, trauma to major vessels is a
not uncommon clinical occurrence. These are acute
events demanding immediate intervention to save life
and limb and precluding any attempt at transfer or
referral. Therefore, the particular specialized surgical skills,
techniques and materials for the care of these patients
need to be at the disposal of the trauma surgeon. It is
the purpose of this position paper to discuss neck, chest
and extremities trauma, bringing to light recent evidence
based data as well as expert opinions. Also, this will
focus on the treatment of injured arteries, although
attention will be given to those venous injuries, which
require surgical repair rather than simple ligation.
The literature is filled of epidemiological researches
demonstrating the features of vascular trauma in a
variety of countries [1–9]. There is wide variation in the
incidence, cause and mechanism of injury depending on
geographic conditions. In Australia vascular injuries
represent 1–2 % of total trauma patients [5–9], however it
account for 20 % of all trauma related death . Deaths
from vascular injury diverge considerably with anatomic
location and mechanism of injury. Thoracic vascular
injuries routinely have death rates between 30–50 %;
vascular injuries to extremities are significantly lower in the
range of 5 %, in a civilian reality. In an unparalleled large
study from Vietnam, Rich and colleagues  reported a
total death of only 1.7 % for all vascular injuries. It may
be that life-threatening vascular injuries were
preselected by their failure to survive transport. In the
current warfare conditions of the American intervention
in Iraq and Afghanistan,Fox and his group reported that
vascular trauma represents 7 % of total battle injuries,
88 % of these were extremity injuries . The
amputation rate was only 8 % after vascular repair. In North
India , with a low risk of personal violence, blunt
injuries, mostly motor vehicle accidents, account for 84 %
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of vascular injuries. Whereas in Medellin, Colombia 
93 % of vascular injuries are penetrating and in Georgia,
USA they represent 85 % of the total . Surprisingly, in
the western European experience , up to 40 % of
vascular injuries are iatrogenic, as a result of vascular and
other surgical interventions. Jaha et al, recently reported
a survival rate of plus 95 % for multiple mechanisms of
vascular injuries in Kosovo, most of those were
penetrating peripheral vascular trauma (78.3 %) . Kuwait 
strikes a middle ground with 41 % penetrating, 23 % a
result of road traffic accidents (RTA). In Malaysia ,
over 50 % of vascular injuries occur as a result of RTAs
differently from a British Trauma Center experience
. As far as anatomic site of injury is concerned,
variability is less. In Australia [5–9] injuries are split almost
equally between thorax, abdomen and upper and lower
extremities, with cervical injuries being less common. In
Latin America , extremity injuries are twice as
common as thoracic and abdominal, although these later
result in a higher mortality [14, 15]. As far as extremities
are concerned upper and lower injuries occur with
similar frequency and the brachial, femoral and popliteal
arteries are the most commonly injured vessels .
General principles for vascular injuries
Before specifically talk about neck, chest and extremities
vascular injuries some basic principles must be reviewed.
Traumatic vascular lesions in general have a similar
pattern of injury. They are either penetrating or blunt.
Still, can be subdivided into high/ low velocity
penetrating injury (i.e.: war caliber rifle injury, hand gun injury,
shotgun injury, stab wound); blunt vascular injuries
caused by joint displacements, bone fractures,
contusions; blast injuries provoked by mines, improvised
explosion devices, bombs, shrapnel, etc.
In one way or another, the pattern of injury is straight
related to the kinetic energy and stretching force, ending
up in general, in a similar injury-type such as contusion,
total/partial transection and arterio-venous fistulae.
Actual management though, may vary depending on the
mechanism of injury.
Table 1 Hard signs and soft signs of arterial injury [17–19]
Hard signs of arterial injury
(Requires immediate surgery)
External arterial bleeding
Rapidly expanding hematoma
Obvious arterial occlusion (6 p ‘s: pulseless, pallor, paresthesia, paralysis, poikilothermia)
The watershed here is to determine whether or not the
presenting patient has palpable pulses. Clinical
examination is paramount in these vascular trauma situations
and the presence of distal palpable pulse (when possible to
measure), even if diminished, already suggests that
proximal artery injury is limited. Serial clinical examinations
are mandatory. Use of a hand held bedside Doppler is
extremely helpful. Table 1 presents hard/soft signs for
arterial injuries, which are important to determine medical
Key management principles on vascular injuries
The care of a trauma victim begins with initial
assessment and resuscitation according to the ABC Principles.
These do not vary for those trauma patients with
Standard exposures for major arteries and veins are
well defined and should be adopted in regular trauma
cases. Specific surgical techniques must be mastered if
successful vascular repair is to be achieved. These
include: proximal and distal exposure for control with
vascular clamps and loops; dissection and isolation of
injured vessels including veins; heparinization (local and/or
systemic); use of vascular sutures; magnification loops;
assessment of injury: debridement, contusion, intimal flap
and distal dissection and thombosis; selective use of
temporary shunting (Argyle); anatomic repairs: with vein
patch, end/end anastomosis without tension and reversed
autologous vein graft for larger defects; technical details of
spatulated ends, running versus interrupted sutures; distal
thrombectomy; completion arteriography; fasciotomy and
soft tissue coverage. Proper handling of the autogenous
vein graft is important.
Attention is needed for peripheral vascular trauma in
general when compartment syndrome is a complication
risk factor. Suspect of compartment syndrome if
prolonged period of shock, arterial occlusion, combined
arteriovenous injury, need for arterial or venous ligation,
crush injuries, massive tissue damage and swelling. In
such cases, fasciotomy is mandatory [20, 21].
Soft signs of arterial injury
(Consider further examination)
History of arterial bleeding at the scene
Proximity of penetrating/blunt trauma to major artery
Diminished unilateral distal pulse
Small nonpulsatile hematoma
Abnormal Ankle-Brachial pressure index (<0.9)
Abnormal flow-velocity waveform on Doppler ultrasound
Key principles: author’s recommendations
Gain proximal and distal vascular control before
attempting to explore a hematoma.
Avoid large vessels dissections when not necessary,
but value good injury exposure.
Get aware about patient’s total trauma burden and
Decide for vascular damage control early in time
Balloon catheters (i.e.: Fogarty) proximal and distal
to artery repair, before shunt insertion.
Regional Heparin (50 units/ml) for arterial injuries
(proximal and distal to repair). Analyze if systemic
heparinization is possible.
Completion arteriography, if patient is stable.
Venous repair is not a must.
Perform fasciotomy when indicated.
Neck vascular trauma
Blunt neck vascular injuries
Blunt neck trauma (BNT) is known to be rare occurring
about 5 % of time of all neck traumas. There are various
sources of blunt neck trauma and each is associated with
a specific pattern of injury.
Vascular injury occurs in 1–3 % of all BNT and is
associated with 20–30 % mortality. It mostly occurs with motor
vehicle collisions. Rapid deceleration causes hyperflexion,
hyperextension, and rotation of the neck. As a result, the
vascular structures are stretched over the cervical spine
leading to shearing forces on the vessels and subsequent
intimal tears in the vessel wall. Hard signs and soft signs
of injury must be detected. Often blunt vascular injury
initially manifests in the form of acute ischemic stroke and
can be delayed in onset . Classic presentation includes
a neurologically intact patient who develops hemiparesis
after a high-speed motor vehicle crash. Evaluation by
four-vessel angiography remains the gold standard given
its sensitivity of 99 % but it is invasive and has a significant
complication rate. CT Angiogram (CTA) has excellent
accuracy in detecting clinically significant injuries [23, 24].
These modalities can be used as adjuncts to evaluation
but are not first-line. Duplex Ultrasound has sensitivity of
90–95 % but it is operator dependent. In general, surgical
repair is preferred over ligation and primary repair is
preferred over grafting .
Penetrating neck vascular injuries
Penetrating neck wounds are often dramatic and require
immediate action. When the penetrating mechanism
transects the platysma, it is not unclear whether patients
without obvious vascular or visceral cervical injuries
should not undergo routine exploration: selective
exploration is the standard of care . Penetrating injuries to
the neck have been divided into three zones: zone 1,
from the sternal notch to cricoid cartilage; zone 2, from
the cricoid cartilage to the angle of the mandible; zone
3, from the angle of the mandible to the skull base.
Suspected vascular injury in zones 1 and 3 in the
presence of hard signs of intra-cranial dysfunction mandates
arteriography prior to exploration. Zone 2 injuries are
recommended to undergo prompt exploration. Study of
the neurologic outcomes in neck injuries shows that the
risk of cerebral infarction is unpredictable but that repair
of injured vessels gives a more favorable outcome than
Penetrating injuries to the neck also can vary on its
mechanism. Glass-Coated kite lines – Fig. 1 , Stab
wounds, GSW, etc. Gunshot wounds are challenging
injuries to repair, are usually related to severe vascular
injuries, pharynx, airways, GI, thorax. Help of an
interventional radiologist for an endovascular approach is
frequently required. Injuries to the vertebral artery can
be tricky and very difficult to approach, especially in its
zone III topography just before becoming the named
basilar artery. Endovascular obliteration of the
vertebral artery (VA) as well as its ligation may be preferred
and a plausible solution in an extremis situation,
although exposure of the VA isn’t easy and you may not
have fast access to the angiographic suite for an
endovascular procedure. In such cases, pushing a piece of
bone wax into the bleeding hole usually works fine
and stops the brisk bleeding coming from the VA.
Internal Jugular Vein may also be ligated as a damage
For the carotid artery (CA) injuries we suggest you
to go simple with no cool repairs or exotic maneuvers.
Occasions affording simple repairs or end-to-end
anastomosis are rare. To our experience they are
usually present in low energy clean lacerations such as
stab wounds caused by a dagger for instance. Our
Fig. 1 Glass-coated kite line zone II neck injury
recommendation to these low complex injuries is
primary repair, the use of a synthetic graft or patch to
reconstruct the carotid depending on how large is the
defect, when patient’s physiology allows you to
proceed with this. When patient is about to breach the
physiologic envelope or when there is multiple life
threatening injuries associated, ligation of the CA is a
valid option. When considering ligation you may be
deciding for saving the patient’s life with the risk of a
neurologic deficit, such as a stroke. When breaking
through a zone III CA ligation is your only realistic
Evaluate the neck fully. A C-Spine collar might
obscure wounds. Take off the dressings.
Value the mechanism of injury in blunt neck
Be aware of insidious vascular injuries in BNT.
Clinical signs can be similar to a stroke in BNT.
Evaluate the location of the wounds to get a
sense of the neck zone.
If the wound does not penetrate the platysma, then
it is likely that no further evaluation is required and
the patient can be discharged home. If platysmal
penetration is not certain, then a CT scan can be
performed to rule out penetration.
A CXR should be obtained in all circumstances
(assuming the platysma has been penetrated).
External hemorrhage should be managed by direct
pressure. Do not probe/explore the wound. Insertion
of an NG tube should be withheld until the patient
is in the operating room.
Patients should be evaluated specifically with a
history and physical evaluating for changes in
phonation, odynophagia, cranial nerve
abnormalities, paresthesia or weakness in the
extremities. Horner’s syndrome (miosis, ptosis,
anhydrosis) is often missed as are physical evidence
of injuries to the hypoglossal or spinal accessory
nerve. If intact, document the normal exam.
Exploration requires evaluation of the carotid sheath
and its structures, the esophagus, and the larynx/
trachea. The trajectory of the impaling instrument/
missile should be followed. Areas might be omitted
from exploration if they are not in the trajectory.
Chest vascular trauma
Blunt thoracic vascular injuries
Blunt thoracic aortic injury is the most severe thoracic
vascular injury. This is a specific clinical syndrome
related to high impact deceleration injuries and high injury
severity scores. Although treatable, it causes significant
mortality related partially to delayed diagnosis .
About 50 % of victims die on impact, in the rest the
bleeding is temporarily contained by the aortic adventitia
and pleura and these patients are potentially salvageable.
The injury typically occurs at the site of the ligamentum
arteriosum, just distal to the take off of the left
subclavian artery. Shear forces and stretching of the aorta
are likely mechanisms of injury. The classic sign of
widened mediastinum is unreliable and investigation should
be carried out in cases where there is a high index of
suspicion . No controversy remains regarding arch
arteriography or CT scanning: Moore et al.
demonstrated CT had essentially 100 % negative predictive
value . It appears that the use of heparin-bonded
shunts allows improved results with a lower incidence
of paraplegia. Endovascular techniques are playing an
expanding role in the treatment of this problem .
Massive hemothorax requiring thoracotomy is defined
as plus to 1–1.5 L at the time of insertion of chest
drains or 200–300 ml/hr for the subsequent 4 h. Some of
these cases will involve injury to the pulmonary vessels
[33, 34]. Operative repair of aortic arch is through a
median sternotomy and may require use of total
cardiopulmonary bypass and insertion of a graft.
The overall incidence of blunt aortic injury has remained
the same over the past 12 years despite advances in vehicle
restraint systems .
Similar mechanisms are implicated in the injury of the
non-aortic great vessels as well. Regardless of the
mechanism or mechanisms, the result is vessel wall
disruption, occlusion, or avulsion. Shearing can result in all of
these and compression more often results in occlusion.
A small intimal disruption can lead to thrombus
formation and subsequent vascular occlusion . Innominate
artery and left carotid injuries usually occur proximally
at the vessel origin. In contrast, blunt subclavian injuries
tend to be more distal [11, 35].
Comparing those patients with penetrating injury,
blunt thoracic great vessel injuries are less incident.
In general, penetrating injuries result in higher
mortality, more combined arterial and venous injures, and
lower morbidity than those presenting with blunt
trauma. Mortality for blunt injury has been reported
between zero and 24 %.
Penetrating thoracic vascular injuries
In thoracic penetrating injuries, the trajectory of the
projectile or of the blunt object is the key to determine the
anatomic structures involved. In general, missile
trajectories that pass through the midline are at more risk for
significant vascular injuries [36, 37].
Penetrating injuries involving the ascending arch of
the aorta are uncommon. Survival rates approach 50 %
for patients having stable vital signs on arrival at a
trauma center. Although primary repair of anterior
lacerations can be accomplished without adjuncts,
cardiopulmonary bypass may be required if there is an additional
For an injury to the transverse aortic arch, extension
of the median sternotomy to the neck allows complete
exposure of the arch and brachiocephalic branches. If
necessary, exposure can be enhanced further by division
of the innominate vein. Simple lacerations may be
repaired by lateral aortorrhaphy. With difficult lesions
such as posterior lacerations or those with concomitant
pulmonary artery injuries, cardiopulmonary bypass can
be employed .
Patients with thoracic vascular injuries are either
exsanguinating or have a potential bleeding contained
injury. In one way or another one should be followed up
in a TICU or SICU.
Bellow you find author’s recommendations for both
blunt and penetrating mechanism of injury.
Authors recommendations by vessel injury
Innominate Artery& Descending Thoracic Aorta
The proximal innominate artery and aortic arch are
best approached by a median sternotomy. Early
ligation of the innominate vein as well as associated
thymic tissue in the anterior mediastinum will aid in
exposing the aortic arch.
The proximal descending aorta is approached by a
Traumatic blunt ruptures of the aorta are typically
found just distal to the ligamentum arteriosum.
For selected patients with only partial tears of the
aortic arch, a continuous lateral arteriorrhaphy
using 4–0 polypropylene suture is occasionally
If patients have stable thoracic hematomas and
concomitant abdominal injuries for which they are
unstable, laparotomy should be the initial procedure.
For patients with rapidly expanding mediastinal
hematoma, however, repair of thoracic injuries
should be the primary therapeutic goal.
Injury to the descending thoracic aorta is
approached by way of a postero-lateral thoracotomy
through the fourth intercostal space.
The current standard technique of repair involves
vascular clamping and direct reconstruction. Three
commonly employed adjuncts to this approach
include pharmacologic agents; temporary, passive
bypass shunts; and pump–assisted left heart bypass.
Vascular clamps are applied to the aortic arch, distal
aorta, and left subclavian artery. Close
communication between the anesthesiologist and
surgeon should occur to maintain stability of
hemodynamic parameters. The hematoma is
entered, and care is taken to avoid indiscriminate
ligation of intercostal vessels; only those required for
adequate repair of the aorta should be ligated. The
proximal and distal ends of the aorta are completely
transected and dissected away from the esophagus.
The injury then is repaired by either end–to–end
anastomosis or graft interposition.
The authors have advocated simple clamp-and-repair
for injuries to the descending thoracic aorta
(without the use of systemic anticoagulation or
shunts), a technique that continues to be used
with excellent results.
Regardless of the technique used, paraplegia
occurs in approximately 8 % of patients
undergoing to descending thoracic aorta repair.
Unless operative time is <30 min, partial left
heart bypass is superior to clamp-and -sew in
For subclavian injuries, a cervical extension of a
median sternotomy is employed for exposure of
right–sided subclavian injuries. For left subclavian
artery injures, proximal control is obtained through
an anterolateral thoracotomy (third intercostal
space), while a separate supraclavicular incision
provides distal control.
In subclavian vascular trauma, a high associated rate
of brachial plexus injury is seen.
Documentation of preoperative neurologic status is
important, in all thoracic and neck vascular injuries.
Repair of subclavian arteries can usually be
accomplished with either lateral arteriorrhaphy or
graft interposition. Any difficulty in exposure can be
managed with division or resection of the clavicle
exposing the more distal subclavian.
Subclavian reconstruction commonly requires the
use of a graft (Dacron or PTFE). In the patient, in
extremis flow can be reestablished with the use of a
shunt, or the artery can be ligated as a life–saving
Operative exposure of the subclavian veins is
equivalent of that described for subclavian artery
injuries: median sternotomy with cervical extension
for right-sided injuries and left anterolateral
thoracotomy with a separate supraclavicular
incision for left-sided injuries.
Repair should be performed by either lateral
venorraphy or ligation.
Pulmonary artery & veins
The intrapericardial pulmonary arteries should be
approached via median sternotomy.
Exposure of the intrapericardial right pulmonary
artery is achieved by dissecting between the superior
vena cava and the ascending aorta.
Mortality rates for injury to the central pulmonary
arteries or veins are high (>70 %).
When there is a major hilar injury, rapid
pneumonectomy may be a lifesaving maneuver.
Injuries to the pulmonary veins are difficult to
manage through an anterior incision.
With major bleeding, temporary occlusion of the
entire hilum may be necessary.
If a pulmonary vein must be ligated, the appropriate
lobe will need to be resected.
Extremities vascular trauma
Injuries to the upper extremity vessels are common,
usually penetrating and may be associated with significant
nerve and orthopedic injury. Blunt injury is usually a
result of supracondylar fracture of the humerus or
dislocation of the elbow. The amputation rate for ligation of the
common brachial vessel varies from 18 to 55 %. With
isolated injury to the infra-brachial vessels the
amputation rate is lower and ligation of either the radial or
ulnar arteries alone is usually well tolerated. A higher
level of technical skill is required in dealing with smaller
vessels and use of magnification loops is recommended.
Spasm of the vessels is frequent and may require topical
lidocaine or intra-arterial papaverine. Generally, prosthetic
materials are not recommended. Passing of Fogarty
catheters proximally and distally is important to remove
eventual thrombus. Completion angiograms are important to
detect abnormalities, which might result in post-operative
thrombosis of the repair. Soft tissue coverage of the repair
uses adjacent muscle. Fasciotomy needs to be done if
ischemic time is prolonged and orthopaedic stabilization
should occur after vascular repair [16–18].
Gain rapid access to axillary vessels through the
pectoralis major muscle, extending the incision from
the mid-clavicle to the deltopectoral groove.
Damage control options for axillary artery are
not many: shunt insertion, fasciotomy and/or less
Gain rapid access to the brachial vessels through a
incision along the groove between the biceps and
Take the median nerve as your anatomic landmark.
Damage control options for brachial artery are
ligation (well tolerated) and fasciotomy.
Definitive care is usually using a saphena vein
interposition graft harvested just above the ankle.
As for upper extremities, penetrating injuries are more
often common in the lower extremities. Pre-operative
angiography may not be useful in severe trauma when
taken the patient to the operating room for exploration
is the best option. Surgically the use of shunts may be
helpful as a damage control option, however local
heparinization, passing fogarty catheters and
completion angiograms can also be obtained. In general,
simple vessel injuries are repaired, complex injuries ligated.
If grafting is required contralateral reversed saphenous
vein is recommended. Fasciotomies should be indicated
based on clinical grounds and performed in all cases of
prolonged ischemia time, in severe limb injuries or
when there are tense compartments, combined arterial
and venous lesions, in the presence of motor or sensory
defect or in limbs of questionable viability. In war
related injuries to the extremity fasciotomies are
prophylactically recommended . Primary amputation
should be carried out, if the superficial posterior and
one other compartment shows non-viability or in cases
of devastating injuries to the limb. The amputation rate
varies from 16 to 20 % and may be larger in war
scenario. Attention should be given to soft tissue injuries
associated to vascular lesions. Infectious complications
and soft tissue injury contribute to late amputation
after severe lower extremity trauma [8, 10–13, 39, 40].
Prepping the contralateral leg for possible harvesting of
the long saphenous vein should be remembered.
Seventy percent of all peripheral vascular injuries in urban
trauma centers are due to femoral injuries. The superficial
femoral artery is most incident . The most common
complication is compartment syndrome (±19 %) and deep
venous thrombosis (±13 %). In an American Civilian Trauma
Center the fasciotomy rate for femoral vessels varies in
around 14 %. Amputation rate in these centers are low .
If there is urgent indication go into the abdomen
and control the external iliac artery in the pelvis.
Vertical groin incision is the simplest way to gain
proximal control of the femoral artery.
Blunt dissection is recommended in devastating
The source of persistent back bleeding is frequently
the deep femoral artery. This must be identified and
Temporary shunt and ligation are plausible damage
control options for femoral vessels (Shunting is a
much better option for arterial injuries). Don’t
hesitate in ligate the femoral vein if needed.
Temporary shunt for common and superficial
femoral arteries is an excellent damage control
solution. Authors strongly recommend a pre-emptive
fasciotomy in such cases.
Interposition PTFE grafts are well tolerated.
Always cover your arterial vascular suture with
viable well-vascularized soft tissue.
Decide (with the orthopedic surgeons) to achieve
bone alignment prior to arterial repair.
Popliteal vessels Blunt injuries are more often present
and carry almost 3 times the risk of amputation in
comparison to penetrating injuries. Popliteal vessels are
challenging to approach and treat. It is the least
accessible vessel in the lower extremity and the
collateral flow around the knee is not sufficient to sustain
viability of the lower leg if flow of the popliteal
artery is interrupted. Popliteal artery traumatic injuries
carry the highest limb loss rate of all extremity
vascular injuries. Injuries requiring resection of more
than 2 cm are not amenable to primary anastomosis.
Popliteal vein injuries, which usually occur together
with arterial injuries, should be repaired if possible,
but never delay the surgery time in physiologically
crashed patients. In the case of combined injuries
intra-arterial shunts may play a particular role.
Prophylactic fasciotomy is recommended in delayed
injuries or those with complex soft tissue damage. In
the usual case of major soft tissue trauma the
decision is often one of primary amputation versus
repair. The absolute indications for primary amputation
in these cases are: more than 6 h of ischemic time
and disruption of the posterior tibial nerve. The
relative indications are: severe foot wounds, multiple
trauma, injuries requiring extensive soft tissue
coverage and tibial reconstruction [42, 43].
Abdominal vascular injury
Abdominal vascular injury (AVI) is defined as a trauma of
the intra- and retro-peritoneal principal arteries and veins,
accounting for the 27–33 % of all vascular trauma, and for
the 25 % of all the abdominal injuries. The 90–95 % of
AVI occurs after penetrating trauma, with incidences of
10 % after stab wounds and 25 % after gunshot wounds,
respectively . Particularly, combined injuries involving
arteries and veins are common after penetrating trauma
and frequent for the iliac and superior mesenteric vessels
because of their anatomical proximity .
Penetrating trauma produces AVI by different mechanisms.
Through-and-through perforation or lateral defects in the
wall will lead to contained haematomas, which are either
pulsatile and expanding (arterial) or non-pulsatile (venous).
Only a small number of patients have free haemorrhage into
the peritoneal cavity. Complete transections are rarely seen,
probably because uncontrolled bleeding from a large-size
vessel leads to exsanguination in the pre-hospital setting. On
occasion, the trajectory of a missile may be in proximity of a
visceral vessel and causes a thrombosis due to the disruption
of the intima from the blast effect. The rarest injury related
to penetrating trauma is an artero-venous fistula, usually in
the upper abdomen or in the iliac area.
Blunt trauma may induce AVI by deceleration forces,
direct anterior crushing (lap-type seatbelt) or posterior blow
(direct compression) of the structures. Two different types
of injury may be caused by deceleration forces. The first
one is the avulsion of small branches from the major vessels
(i.e intestinal branches from superior mesenteric artery).
The second is the partial intimal tear with a secondary
thrombosis of the lumen, or full-thickness tear with a
secondary pseudoaneurysm. A direct anterior crush and
posterior blow may lead to vascular damage by an intimal tear
or flap with secondary thrombosis (i.e “seat-belt aorta”),
and disruption of a vessel (i.e superior mesenteric artery or
vein at the base of mesentery). A complete wall disruption
leads to a massive intraperitoneal haemorrhage, while
partial disruption produces a false aneurysm .
Areas of AVI
Although any vessel in the abdomen can be injured, the
term abdominal vascular injury usually refers to injury
of major vessels located in specific “geographic” zones,
as listed below:
1. Zone 1: Midline retroperitoneum.
Supramesocolic area: suprarenal abdominal aorta,
celiac axis, proximal superior mesenteric artery,
proximal renal artery, superior mesenteric vein
(either supramesocolic or retromesocolic);
Inframesocolic area: infrarenal abdominal aorta,
infrahepatic inferior vena cava;
2. Zone 2: Upper lateral retroperitoneum (renal artery, renal vein)
3. Zone 3: Pelvic retroperitoneum (iliac artery, iliac vein)
4. Portal-retrohepatic area: (portal vein, hepatic artery,
retrohepatic vena cava).
abdominal bruit and haematuria suggest an acute
aortocaval fistula. In patients arriving with a blunt or
penetrating abdominal trauma with profound hypotension or
peritonitis and positive ultrasound (FAST-Focused Abdominal
Sonography for Trauma), a time limit of less than 5 min
in the emergency room before surgery is mandatory and
CT scan is not recommended.
As a general rule, all haematomas in zone 1 (either
supramesocolic or inframesocolic) from either penetrating
or blunt trauma have to be explored. In addition,
haematomas from penetrating wounds in zone 2 and 3, and in
the porta hepatis need to be opened. In contrast,
haematomas from blunt trauma that are located in zones 2 e 3 or
in the retrohepatic area are explored only if they are
pulsatile, expanding rapidly, or have already ruptured. The
classification system is applied to extra- parenchymal vascular
injuries, according to the Organ Injury Score (OIS) Table 2
. It is important to be aware that potential visceral
injuries (i.e, duodenum, colon, stomach, small bowel, etc.)
may be associated to any AVI.
Upon physical examination, the findings in patients with
AVI, after either blunt or penetrating injury
mechanisms, depend on whether a contained haematoma or
uncontrolled haemorrhage is present. Patients with a
contained haematoma, particularly those with venous
injuries, may be hypotensive, but will respond rapidly to
infusions. In this case contrast CT scan is the diagnostic
tool of choice. Other patients with uncontrolled
haemorrhage are hypotensive and non-responsive to fluid
infusion, with a tight abdomen, due to intra-peritoneal
active bleeding from the damaged vessel. Abdominal
distension in association with signs of acute anemia
and/or haemorrhagic shock is a strong indicator of a
major AVI. Another important physical finding is the
loss of the pulse in the femoral artery in one of the
lower extremity when the ipsilateral common or
external iliac artery has been transected or is thrombosed.
Rarely, the patient may be hypotensive, with a copious
emesis of dark blood. In this case, a caval-duodenal
fistula is suspected. The presence of a wide pulse pressure,
In the operating theatre, the patient lays in the supine
position, with both arms fully abducted. The operative field
extends from chin to above the knees and between the
posterior axillary lines, in order to provide free access to
the abdomen, chest wall and both groins. If the patient
arrives profoundly hypotensive or experiences
cardiopulmonary arrest in the operating room, an immediate
anterolateral thoracotomy with aortic cross-clamping is
performed prior to entering the abdomen. Differently, if
the patient arrives with some degree of haemodynamic
stability, but deteriorates during laparotomy, the
abdominal aorta can be controlled digitally at the hiatus through
the lesser sac or by cross-clamping. A wide vertical
midline incision is carried from the xyphoid to the pubis. All
clots are removed and a rapid inspection is performed to
visualize a contained haematoma or an ongoing
haemorrhage. Active bleeding from a solid organ is controlled by
packing, while formal proximal and distal vascular control
is essential for an active haemorrhage from major
intraabdominal vessels. Once haemorrhage has been controlled,
any eventual gastrointestinal spillage is addressed, to avoid
further contamination during vascular repair. Conversely, if
a contained haematoma is present, occasionally the
surgeon has time to control the gastrointestinal contamination
first, and subsequently to open the retroperitoneum
exposing the underlying vascular injury.
Table 2 Classification system of abdominal vascular system [17–19]
Right, left, common hepatic artery, splenic artery/vein, right or left gastric arteries, gastroduodenal artery, inferior mesenteric artery/vein,
primary branches of mesenteric artery/vein
Superior mesenteric vein trunk, renal artery/vein, iliac artery/vein, hypogastric artery/vein, vena cava, infrarenal
Superior mesenteric artery trunk, celiac axis proper, vena cava suprarenal and infrahepatic, aorta, infrarenal.
Portal vein, extra-parenchymal hepatic vein, vena cava retrohepatic or suprahepatic, aorta suprarenal, subdiaphragmatic
(a) in the case of a confined haematoma, the vascular
control is achieved by a left-sided medial visceral
rotation, including the colon, kidney, spleen, tail of
the pancreas and the fundus of the stomach. One
alternative is to leave the left kidney in its fossa,
thereby eliminating the potential damage resulting
from rotation of this organ. The transection of the
left crus of the diaphragm at 2 o’ clock position
allows the exposure of the distal thoracic aorta and a
vascular clamp is applied to obtain supraceliac aortic
(b)in the presence of an active haemorrhage a manual
compression may be performed. Alternatively, the
lesser omentum is entered manually, the stomach
and esophagus are retracted to the left, and the
fibers of the aortic hiatus divided manually to obtain
a quicker proximal control. Distal control of the
aorta in this location is challenging because of the
presence of celiac axis and superior mesenteric
artery. If the ligation and division of the celiac axis
are required, the surgeon must be aware of the
potential gallbladder necrosis, as likely consequence.
Cholecystectomy is warranted, although it may be
performed during re-exploration, if damage control
techniques are required. Another possible approach
is an extended Kocher manoeuvre, by moving the
duodenum and head of the pancreas to the left, in
order to expose the suprarenal abdominal aorta.
Suprarenal aorta (SA)
Small perforating wounds at the SA are repaired by 3–0
or 4–0 polypropylene lateral sutures. If two small
perforations are adjacent to one another, they should be
connected and the defect closed transversally. If the closure
of the perforations results in a significant narrowing of
the lumen, or in the presence of a large defect, a patch
aortoplasty with polytetrafluoroethylene (PTFE) is
required. Occasionally, patients with extensive injuries
require insertion of a synthetic vascular conduit or
vascular graft, after resection of the involved area . It
is important to remember that suprarenal cross-clamping
in presence of a haemorrhagic shock induces a severe
lower extremities ischemia, with a subsequent reperfusion
injury, once the haemodynamic stability has been restored.
Compartment pressure of the legs needs to be measured
before moving the patient from the operating room, and if
this is higher than 30–35 mmHg, two-incision with
fourcompartment fasciotomies are recommended.
Celiac axis (CA)
Injuries of the branches of the CA are difficult to repair
because of the dense neural and lymphatic surrounding
tissue, and the small size of these vessels in a patient in
shock with secondary vasoconstriction. If the left
gastric artery and splenic artery are injured, these vessels
should be ligated. Splenectomy must be performed if
the splenic artery has been ligated. The larger diameter
of the hepatic artery sometimes allows a lateral
arteriorraphy, end-to-end anastomosis or the insertion of a
graft. However, the surgeon has the option to ligate the
vessel proximal to the origin of the gastroduodenal
artery, since the collateral flows from the midgut through
this artery will maintain the viability of the liver.
Superior mesenteric artery (SMA)
The SMA is anatomically divided into four zones (Fullen
zones) (Figs. 2 and 3), and the management of any injury
of this vessel depends on the level of injury itself. If the
injury is located behind or beneath the pancreas (Fullen
zone 1 and zone 2, respectively), the transection of the
pancreas, or a left-side medial visceral rotation, or
elevation of transverse mesocolon, allow a direct clamping of
the proximal SMA. Under all of these conditions, the
artery may be ligated, and theoretically, the flow from both
the foregut and the hindgut maintains the viability of the
midgut (through the middle colic artery). In patients in
shock and vasoconstricted collateral flow may be
ineffective and the insertion of a temporary intraluminal shunt
into the debrided ends of SMA is a better choice, with
definitive repair during a second-look procedure. Injuries to
the distal SMA (Fullen zone 3, beyond the middle colic
branch, and zone 4, at the level of the enteric branches)
should be repaired to avoid intestinal ischemia. If this
cannot be accomplished, ligation of the artery requires an
extensive resection of the ileum and right colon.
Fig. 3 a Abdominal CT with IV contrast of a patient with symptomatic AAA. b Non-contrast abdominal CT of the same patient after collapse
about 2 h later. The AAA ruptured as is evident from the retroperitoneal hematoma
Superior mesenteric vein (SMV)
A part of the SMV is retro-pancreatic and difficult to
expose, and has abundant collaterals. It may be approached
through a Kocher and Cattell Braasch maneuver and
repaired with a continuous row of 5–0 polypropylene
sutures. If multiple vascular and visceral injuries are present,
in a young patient, ligation of the SMV can be performed.
A vigorous fluid resuscitation is needed, as a splancnic
hypervolemia leads to peripheral hypovolemia for at least
3 days after ligation.
Management of injuries in zone 1: inframesocolic
Exposure and vascular control
To expose an inframesocolic injury of the aorta or caval
vein (IVC) the transverse mesocolon is pulled upward,
small bowel eviscerated toward the right side, and the
midline incised from the left renal vein to the origin of
iliac vessels. In case of a large retroperitoneal
haematoma, it should be remembered that the hole in the
aorta is usually under the highest point of the
haematoma (Mount Everest Phenomenon). A rapid finger
splitting brings the surgeon to the injured area. Distal
vascular control is achieved by dividing the
retroperitoneum downward until aortic bifurcation. An injury
involving IVC has to be suspected if the haematoma is
more extensive to the right side. In this case, IVC
control is obtained by a right-sided medial visceral rotation
(Kocher and Cattell Braasch). The two areas in which
the proximal and distal control of IVC are difficult to
obtain are at the confluence of common iliac veins and
at the junction of the renal veins. In the first setting it
is possible to divide the right common iliac artery
allowing the exposure of the iliac vein bifurcation. The
artery will be reconstituted by an end-to-end
anastomosis. In the second case, the medial rotation of the
right kidney permits the application of a clamp.
Another technique, which is useful for controlling
bleeding from IVC in all locations, is the trans-femoral
insertion of a Foley catheter, for tamponade.
Injuries of the infrarenal aorta are repaired primarily
with 3–0 or 4–0 polypropylene sutures, patch
aortoplasty, end-to-end anastomosis, or graft. In the young
patient, when a graft is used or an extensive repair has
been performed, it is better to cover the suture line by a
vascularized pedicle of omentum, in order to prevent an
Anterior injuries of the IVC are best repaired
transversally with a running suture of 4–0 or 5–0 polypropylene.
If a through-and-through perforation is present, the
posterior defect is repaired first, from inside the vessel, with
the first knot tied outside the lumen. If a long
longitudinal suture is performed, the caval vein will appear as
an hourglass, and the narrowing will lead to a
postoperative occlusion of the vessel. If the patient is unstable, a
modification of the repair should not be attempted. In
complex injuries of the young patient, the IVC may be
ligated . In the postoperative course, the
compartment pressure of the legs needs to be measured, and
four-compartments fasciotomies must be done if the
pressure exceeds 30–35 mmHg. An adequate circulating
volume has to be maintained, and elastic compression
applied to both lower extremities. Ligation of the
suprarenal vena cava is performed only if the patient has an
extensive injury at this location and appears to be in
profound shock at the end of the operation.
Management of injuries in zone 2
Exposure and vascular control
Patients found to have a perirenal haematoma following
a penetrating trauma should undergo the haematoma
exploration. If the haematoma is not rapidly expanding,
proximal vascular control is obtained, before entering
the haematoma, by looping the ipsilateral renal vessels.
Proximal renal arteries (RA) are better approached
through the base of the mesocolon, beneath the left
renal vein. Conversely, if there is an active bleeding, the
exposure of the proximal part of the left RA is
accomplished by a left-sided medial visceral rotation and of the
right RA by a Kocher maneuver. The retroperitoneum is
opened lateral to the injured organ, the kidney is
manually lifted upward and a vascular clamp is applied
proximal to the hilum. If a non-expanding haematoma is
detected after blunt trauma, surgical exploration should
not be attempted and post-operative angiography with
interventional radiology repair should be planned.
Renal arteries (RA)
Small perforations from penetrating injury can be repaired
by lateral sutures or resection with an end-to-end
anastomosis. In the presence of large defects, graft interposition
should be considered only if there is a reasonable
possibility to save the kidney. After a blunt trauma, a patient with
an injury to one kidney should be considered for
revascularization only in the presence of stable haemodynamics
and short time of ischemia (less than 5 h).
Renal veins (RV)
A lateral venorrhaphy is the preferred technique for
repair. If right RV has to be ligated, a nephrectomy should
be performed at the same time or at the reoperation if
damage control has been necessary. Left proximal RV
can be ligated as long as the gonadal veins and the left
adrenal vein are intact.
Management of injuries in zone 3
Exposure and vascular control
The proximal vascular control of the iliac vessels is
obtained by eviscerating the small bowel to the right and
opening the retroperitoneum over the aortic bifurcation.
Distal vascular control is achieved at the point the vessels
come out of the pelvis proximal to the inguinal ligament
. When bilateral injuries are present, the only way to
achieve bleeding control is the total pelvic vascular
exclusion, with a proximal cross-clamping of the aorta or vena
cava, above their bifurcation, and a distal cross-clamping
of the external iliac arteries or veins on both sides.
Iliac arteries (IA)
Injuries of the common IA should be sutured or
temporarily shunted if possible. Ligation of these vessels in the
hypotensive patient leads to limb ischemia. In a stable or
stabilized patient, depending on the type of injury, it is
possible to perform a lateral arteriorraphy, an
end-toend anastomosis and an insertion of saphenous vein or
PTFE graft. External IA may be ligated if omolateral
internal IA is intact.
Iliac veins (IV)
Injuries of the IV are best repaired with a 4–0 or 5–0
polypropylene lateral suture or with ligation. If a
significant narrowing of the lumen has occurred after the
repair, postoperative anticoagulation therapy should be
started to avoid thrombosis and pulmonary embolism.
Management of injuries in the porta hepatis
Exposure and vascular control
It is important to be aware that vascular injuries at this
location are frequently associated with an injury of the
common bile duct. Because of this anatomic proximity,
no suture should be placed until the vascular injury is
precisely defined. If haematoma or haemorrhage are
present the Pringle’s maneuver (compression of the
hepatoduodenal ligament between non crushing clamps,
fingers or loops) should be used. The injuries of the
portal vein are best exposed with a wide Cattel-Braasch
maneuver. Exposure of the posterior position of the
vessel requires an extensive Kocher maneuver in association
with a mobilization of the common bile duct toward the
left and the cystic duct superiorly. The approach to
retropancreatic portion of the vessel requires pancreatic
transection followed by distal pancreatectomy once the
repair is made.
Hepatic artery (HA)
Lateral repair or shunt of HA are difficult because of its
small caliber, but desirable. In fact, the portal vein alone
is not always sufficient for liver viability . Ligation of
the gastro-hepatic artery, proximal to the origin of
gastroduodenal artery is usually well tolerated. Ligation of
the right HA requires a cholecystectomy.
Portal vein (PV)
Direct lateral venorraphy with a 4–0 or 5–0
polypropylene suture is the technique of choice. It is better to avoid
any attempt to perform a porto-systemic shunt, because
of the possible onset of encephalopathy at a later stage.
Ligation of PV has a very high mortality. Massive fluid
sequestration induces transient splancnic hypervolemia
that requires a large amount of fluid restoration to avoid
All trauma surgeons must be skilled in the techniques
of emergency abdominal vascular control and repair.
The reduced functional reserve of the unstable patient
with AVI and the presence of multiple injuries require
a damage control approach with staged surgical
strategy. Moreover, an abdominal vascular ligation or repair
in more stable patients needs to be re-explored for the
assessment of visceral viability. Finally, AVI are unusual
after blunt trauma, which in Europe account for 95 %
of trauma admissions. Further, training for the
treatment of these injuries is generally low. For all these
considerations, a patient with an AVI represents one of
the most challenging scenarios for a trauma team and
mortality remains elevated.
Non traumatic emergency vascular surgery
Ruptured aneurysms of the abdominal aorta: current
management and results
Few other surgical emergencies require immediate
diagnosis and treatment like a ruptured abdominal aortic
aneurysm (rAAA). Mortality of patients with a rAAA
reaches 85 %, with more than half dying before reaching
the hospital. Open repair (OR) of rAAA is associated
with perioperative mortality of 40–70 %. Patient age,
haemodinamic instability and pre-existing comordibitidies
are significantly associated with perioperative deaths.
Endoluminal repair of rAAA (REVAR) has emerged as an
alternative to OR. Since the first experience with this
technique in the early 1990s, a substantial decrease in
perioperative and long term mortality has been
demonstrated after REVAR when compared with OR. In
addition to the advances of REVAR, modern resuscitation
techniques including hemostatic resuscitation and
permissive hypotension, and the availability of endoluminal aortic
occlusive balloons for supraceliac aortic control in the
emergency room, has assisted salvaging patients that
historically died before reaching surgery. REVAR mandates
pre-operative imaging, a dedicated team, an angio suite
and ready access to suitable stents.
In this paper we present a review of the recent
literature on rAAA. We discuss the rationale for transfer to
referral center, the role of preoperative imaging and the
pros and cons of REVAR versus OR.
Where should ruptured abdominal aortic
aneurysms be repaired?
A positive correlation between sub-specialization, high
volume and improved outcome has been demonstrated
in multiple surgical procedures, including open and
endovascular operations. Thus, a dilemma occurs: should
an open repair be attempted immediately, by a team and
center with limited experience, or should the patient be
transferred to the referral centre for sub-specialized care
with obvious delay to treatment and risk of
decompensation during transfer? Relatively sparse data is available
on the true effects of transfer of patients with an
unsecured rAAA. A recent case-series in Canada suggests
that while the transfer caused treatment delays (from
approximately 3 to 6 h), it did not significantly impact
mortality (50 vs 54 %) . However, the retrospective
design of this study may have biased by selection of
likely survivors for transfer, and palliation of the sicker
patients. Unfortunately, for vascular emergencies, the
last decade has seen an unchecked drive towards elective
subspecialization with a surge of endovascular procedures
and a rapid reduction of open vascular procedures. In this
environment, the General and Acute Care Surgeons have
lost almost all training in vascular surgery. The large
variations in local practices and expertise, retrieval teams, and
geography preclude a universal recommendation on a
We suggest preemptive, careful design of pathway and
protocols for patients with a rAAA which should be
tailored to individual hospitals and area health. In any case,
preoperative resuscitation should follow the concept of
“permissive hypotension” with the aim of maintaining
consciousness and prevent ST changes, and a systolic
blood pressure between 70 and 80 mmHg [54, 55]. This
can be achieved by limiting infusion of fluids and blood
products and/or pharmacologically reducing the blood
Role of preoperative imaging
While open repair of a rAAA can be “attempted” with
minimal imaging by most surgeons familiar with
abdominal surgery, REVAR introduced the need of pre-operative
CT scan. To allow immediate and accurate imaging
reconstruction, CT should be performed with intravenous
contrast, by a trained radiographer, with the correct bolus
timing, no oral contrast and possibly the availability of
thin axial slices. A good quality CT scan is of paramount
importance to properly assess feasibility of endoluminal
repair and graft sizing (Fig. 3, Fig. 4, Fig. 5). The main
concern of running a potentially unstable patient through a
scanner is the possible delay from ED admission to
surgery. According to Lloydet al.,in not operated patients
with rAAA the mean time from onset of symptoms and
ED admission to death was 16 and 11 h respectively; only
13 % of patients died within 2 h of admission. In case of
transfer, the CT scans can be reviewed online and EVAR
suitability and measurements can be completed before the
patient arrives to the hospital. The lack of protocols for
efficient transfer and management of patients with rAAA,
rather than the time spent in radiology, seems to cause
most delays to surgery [57–59].
Patients with a systolic blood pressure above 80mmHG
should be preoperatively investigated with CT with IV
contrast. Patients with a systolic less then 80 mmHg should be
immediately transferred to theatre with an aortic occlusive
balloon (endoclamp) ready to be inflated in the
supracoeliac aorta. REVAR assessment can then be done with a
digital subtraction angiogram on the operative table.
The open approach to the rAAA has been standard for
several decades. During this time, relatively little has
changed regarding the surgical procedure: first, rapid
Fig. 4 Abdominal CT with IV contrast demonstrating a large infrarenal AAA ruptured in the inferior vena cava in axial and sagittal view
proximal control of the aneurysm is achieved
immediately on induction of anesthesia; second, distal control;
and finally, after a small period of time is afforded to the
anesthetic team to further resuscitate the patient, the
aneurysm is opened and a graft used to bypass the
diseased aorta [60, 61].
Preoperative CT imaging is not strictly necessary, but
still very useful as it can guide in location to achieve
proximal control and possible anatomical variation (such
as a retroaortic renal vein or a horseshoe kidney) or
presence of additional aneurysms.
The rAAA is classically approached through a midline
laparotomy, facilitating a transperitoneal repair. This
approach provides good exposure of the abdominal aorta
and common iliac arteries. The peritoneal exploration
also allows inspection of the abdominal viscera for
secondary pathology. However a retroperitoneal approach
may be preferable in cases such as known supraceliac
Fig. 5 3D reconstruction of large infrarenal AAA ruptured into the inferior vena cava
extension of the aneurysm, a battle-scarred abdomen, or
in patients with atypical anatomy such as a horseshoe
kidney. While there are no randomized data to guide the
type of incision for a rAAA, in cases of elective repair,
randomized trials have produced conflicting results
regarding possible reductions in postoperative ileus and
shorter hospital stays associated with a retroperitoneal
approach [62, 63].
After entering the peritoneal cavity, routine
supraceliac control has traditionally been the first maneuver.
However, when the aneurysm is limited to the infrarenal
aorta, aortic control may be achieved below the renals in
a similar time frame and is a feasible alternative: the
assistant temporarily compresses the supraceliac aorta
against the vertebral body at the diaphragm’s aortic
hiatus, while the surgeon uses fingertip exploration of the
periaortic hematoma to guide an infrarenal clamp. Care
is required to avoid venous injuries to the left renal,
gonadal and inferior mesenteric veins during infrarenal
clamping, as injuries to these veins are associated with a
significantly worse prognosis . For supraceliac
control, however, the left lobe of the liver is first mobilized
and retracted to the right. The nasogastric tube then
facilitates identification of the esophagus, which together
with the stomach is retracted towards the left. This
allows access to the aorta at its diaphragmatic hiatus,
through the lesser sac. Caution is required to avoid the
not infrequent presence of an aberrant left hepatic artery
travelling through the lesser omentum. The aorta can
then be clamped as it emerges between the crura of the
When the rAAA is approached from a retroperitoneal
dissection, the incision is usually placed through a 10th
intercostal space, though in the cases of very proximal
aneurysmal disease, a formal throacoabdominal incision,
with a transpleural aortic cross-clamp, may be required.
Retrospective series report reduced gastrointestinal and
respiratory morbidity, reduced hospital stays and
possible reduced mortality, favoring a retroperitoneal
approach [64, 65]. During this approach, a left medial
visceral rotation facilitates the aortic exposure.
Distal control is usually easier to achieve; the level of
control, and the site for the distal anastomoses, will be
guided by associated vascular pathology in the iliac and
femoral vessels. If a bifurcated graft is used to bypass
iliac disease, attempts should be made to perfuse at least
one internal iliac artery to avoid ischaemic complications
of the pelvis and lower abdominal viscera.
Endoluminal balloons provide an alternative to the
traditional atraumatic clamps, limited by the need for a
careful dissection to avoid injury to adjacent structures.
First described with Foley catheters deployed through
the aneurysm and inflated in the proximal aorta,
endoluminal balloons have become increasingly available and
are associated with reduced intraoperative mortality
. Furthermore, aortic occlusion catheter kits are
commercially available to facilitate blind insertion and
aortic control in the emergency department .
However, blind application of this device is not
recommended in rAAAs.
After proximal and distal control, the largely
decompressed aneurysm may be opened to allow the graft repair.
Red cell scavenging forms a standard part of arAAA
repair. Its use has been clearly linked to improved survival
and reduced post-operative complications [68, 69]. It does
not replace the need to careful assessment and targeted
replacement of blood components, but it does provide a
feasible, cost-effective, method to replace red cell loss
from the vascular space.
Once the aortic reconstruction is completed before
the proximal clamp is released to establish distal flow,
the distal vessels are generously back bled, to prevent
embolization of soft clot that may have formed. This
is particularly important if the patient is neither
systemically nor peripherally heparinized. As indicated by a
recent review, the pro-coagulant, inflammatory stimulus
from the trauma associated with a rAAA and its surgery,
likely favors routine heparin administration. However,
unfortunately a limited number of studies are available to
guide the decision regarding the use of heparin in rAAA.
As such, there remains no clear consensus or practice
guideline to delineate the standard practice [70, 71].
At the completion of the vascular repair,
approximately one quarter of patients will have abdominal
contents too swollen to allow a non-tensioned abdominal
closure, and around half of patients will exhibit an
intraabdominal pressure > 20 mmHg. Historically, these
patients had their abdomens closed under tension with
deleterious consequences. The resultant abdominal
compartment syndrome (ACS) is responsible of multiorgan
failure and increased mortality. A proactive approach to
allow early diagnosis and intervention is required.
Temporary abdominal closure devices with negative pressure
dressing have redefined the standard of care of these
patients [72, 73].
Endoluminal repair: protocols and technique
Endovascular aneurysm repair (EVAR) is the
endoluminal exclusion of an aneurysm sac from the circulation
by the use of an endograft; initially described by Parodi
et al. in 1991 , this technique has evolved and has
been proven safe and effective when compared to
traditional OR in the elective settings [75, 76]. In 1994 the
first successful endoluminal repair of a rAAA was
performed in New York . Today REVAR represents the
most important innovation in rAAA management over
the last 50 years [78, 79]. The protocol introduced by
the Albany group  is efficient and applicable in
most tertiary centers (Fig. 6); it requires
multidisciplinary teamwork and appropriate team training. Once the
ED physician has a suspect of rAAA (clinical or
supported with ultrasound) the vascular team and theatre
staff needs to be immediately notified. A dedicated
theatre fully equipped for open and endovascular surgery
is mandatory; a hybrid suite is ideal, but a standard
theatre with a mobile C-arm intensifier is enough. Stable
patients (SBP ≥ 70–80 mmHg) will have an expeditious
CT scan; unstable patients will be directly transferred
to theatre for endovascular-first approach and
conversion to open if necessary. Patients are usually excluded
from REVAR if (i) the aortic neck length ≤ 10 mm, (ii)
the aortic neck diameter ≥ 32 mm, (iii) neck
angulation ≥ 75° and (iv) bilateral iliac diameter ≤ 5 mm. Using
those anatomical criteria almost 80 % of patients are
feasible for REVAR ; Mayer et al. have recently
reported 100 % feasibility of REVAR over a period of 32
consecutive months, with an exclusion rate of only 4 %
. STAT VASCULAR is the program implemented
by Hodgonsat the University of Southern Illinois (Fig. 7)
. It emphasizes the importance of CT angiography for
all patients suspected of having an acute aortic event
either abdominal or thoracic; positive CT finding activates
STAT VASCULAR and the on-call vascular team. REVAR
can be safely and more effectively performed under local
anesthesia supplemented by analgo-sedation . Femoral
access is achieved either with a cut-down or
percutaneously. The percutaneous approach requires familiarity
with preclose techniques with ProGlide or ProStar closure
devices . Once vascular access is established an initial
glidewire is exchanged for a stiff one over a 5Fr catheter
and a 12–14Fr 45 cm long sheath is placed at the level of
the renal arteries to support an aortic occlusion balloon
(femoral approachis preferred over brachial) [80, 85].
Fig. 6 Flowchart of the rAAA protocol introduced by the Albany Group 
Fig. 7 Flowchart of the STAT VASCULAR program from the University of Illinois 
In hemodynamically stable patients the balloon can be
removed after the initial angiogram and the main body
of the endograft will be delivered through the ipsilateral
groin. In patients in hemorrhagic shock, when the
balloon needs to remain inflated to maintain brain and
heart perfusion, the endograft is delivered through the
contralateral groin and quickly deployed after the
balloon is deflated and retrieved proximally.
Different endografts are available for treatment of rAAA
in both bifurcated and aorto-uniiliac (AUI) configuration
and the device choice depends on the patient’s anatomy
and the surgeon preference. Table 3 summarizes the
characteristics of the most commonly used devices. The use of
AUI devices should be limited to when (i) rapid
cannulation of the contralateral gate is not possible or when (ii)
the contralateral iliac is difficult to access because of
occlusive disease. It is important to have a wide range of
sizes and configurations available off the shelf in order to
accommodate different anatomies. Adjunctive procedures
(extension cuffs, giant Palmaz stents and embolization)
might become necessary to seal on the table a proximal
type for type IIendoleak, especially if causing ongoing
hemorrhage [84, 86]. Finally extending the indications for
REVAR to “all comers” might require visceral debranching
(open or endoluminally with Chimney grafts) if the native
neck is too short [87, 88].
The obvious advantage of avoiding a laparotomy
carries the intrinsic risks of increased incidence of ACS.
Metha reports an incidence of ACS of 18 %, occurring
mainly in patients with pre-operative hemodynamic
instability . They suggest to routinely withhold
systemic heparin in REVAR and to closely monitor the
bladder pressure during and after the case. Increased
bladder pressure alone or signs of end-organ
dysfunction associated with abdominal distention, regardless of
the bladder pressure, warrants decompressive laparotomy.
Mayeret al. suggested an intravescical pressure > 20 mmHg
or an abdominal perfusion pressure < 50–60 mmHg as
indication for open abdominal treatment [90, 91]. Finally,
on-table conversion to open surgical repair might be
needed; the use of the occlusive aortic balloon as
endoclamp can be very valuable to maintain haemodinamic
stability. This needs to be supported to avoid its prolapse
into the AAA with consequent loss of aortic occlusion.
Open or endovascular repair for rAAA?
Patients presenting with a ruptured aorta represent a
medical and surgical challenge for everyone involved in
their care. Rapid diagnosis of this catastrophic condition
triggers an immediate and coordinated series of actions
involving different health care providers. Despite the
advances in medical care and surgical technique, the
perioperative mortality rate of OR has seen only a modest
improvement in the last 50 years [92, 93]. Among many
theories, the “two-hit” hypothesis has been suggested to
explain high mortality secondary to multi-organ failure
; this is summarized by the combination of two
consecutive ischemic events (hemorrhagic shock and aortic
clamping) followed by reperfusion injury. This sequence
seems to be responsible of cardiac contractile
dysfunction and massive neutrophils activation with resultant
generalized peroxidation injury.
In the last twenty years multiple centers around the
world have reported a dramatic reduction in perioperative
mortality following REVAR [54, 74, 79, 95–100]; those
excellent outcomes have been challenged as being the result
of patient selection or publication biases [78, 100–103]. A
meta-analysis of 18 observational studies (>10 cases) of
patients undergoing REVAR; the pooled mortality among
436 pts who underwent REVAR was 21 % (95 % CI 13 to
29) but with substantial heterogeneity among different
studies; however, 90 % of the heterogeneity between
studies was not explained by chance alone. Surgical volume
explained substantial heterogeneity . A prospective
study from 49 centers from all over the world showed an
overall mortality at 30-days of 21.2 % but those results
had an intrinsic selection bias due to the limited use of
REVAR in “stable” patients in most of the centers.
Thirteen centers performed “REVAR whenever possible”
including haemodinamically unstable patients, and 30-days
mortality was 19.7 % for REVAR compared with 36.3 %
for OR (p < .0001) .
So the question is: which patient with a rAAA would
benefit the most of an endograft? Do we have the data
to justify the “EVAR-first” approach on everyone?
Mayer et al. have reported a progressive increase in the
use of REVAR over the years, reaching the up to a
“100 % EVAR” approach. Adjusted 30-days mortality in
the “EVAR/OPEN period” was 15.7 % for EVAR and
37.4 % for OR (p = 0.004). When all rAAA were treated
endoluminally, 30-days mortality climbed to 24.3 % of
“all comers” [81, 90]. Extending the indications for
REVAR to “all comers” had multiple consequences:
“exclusion from treatment” rate fell from 10 to 4 %, at the
expenses of a higher REVAR mortality and more
complex procedures. In addition, in order to accommodate
also unsuitable anatomies, adjunctive procedures were
used in 24 % of the cases, adding a considerable degree
of complexity to an already challenging procedure. A
Kaplan-Meier analysis based on more than 40.000
patients from the US Medicare dataset showed a survival
benefit for REVAR over OR for the first 90 days; after
propensity score matching the benefit persisted over
4 years . Similar findings on long-term survival
were also reported by Mehta et al.(37 vs 26 % REVAR
and OR; p < .005) . In this series almost a fourth of
patients treated with an endograft, required re-intervention
for endoleaks or graft migration, highlighting the
importance of close follow-up.
A recent review based on US Medicare data
beneficiaries used propensity score matching to show a
survival benefit for REVAR (33.8 vs 47.7 %) which persisted
at 4 years. At 36 months, EVAR patients had higher
rates of AAA-related re-interventions than OR patients
whereas OR patients had more laparotomy-related
complications . Based on a cohort of 1447 patients with
rAAA, unstable patients showed less favorable
outcomes: the 30-day mortality for unstable patients was
Flex AAA, Spiral-Z Iliac
18–22Fr (6.0–7.3 mm)
21–26Fr (7.1–8.5 mm)
18–20Fr (6.1–6.8 mm)
20–27Fr (6.8–7.5 mm)
52.8 % for OR and 35.6 % for REVAR (P < .001),while for
stable patients mortality was 26.3 % for OR and 16.4 % for
REVAR (P = .001). Also, in this study REVAR was
associated with a diminished 30-day mortality and morbidity
. Despite the excellent immediate and mid-term
REVAR results reported by observational and
populationbased studies, the level of evidence to support
“EVARfirst” for rAAA is still debatable  and all three
randomized control trials conducted so far failed to prove a
survival benefit with REVAR [106–110]. The first study
was a single center trial conducted in the UK and
published in 2006; it failed to prove a survival benefit for
REVAR over OR, but results were considered inaccurate
because the trial was interrupted when only a third of the
predetermined number of patients was recruited.
The AJAX study  is a three-centers trial
conducted in the Netherlands where 116 patients with
rAAA anatomically suitable for “both” EVAR or OR
were randomized to either treatment. This trial did not
show a significant difference in combined death and
severe complications between the two modalities; 30-days
mortality was 21 % post REVAR compared to 25 % with
OR (ARR = 4.4 %; 95 % confidence interval:−11 to +20 %).
The authors explain the unusually low surgical mortality
with the introduction of round-the-clock acute aneurysm
service, centralization of aneurysm care and routine
preoperative CTA. This study has indeed some significant
statistical and technical limitations. Only 22 % (116/520)
of rAAA diagnosed in the seven years study period met
anatomical criteria for randomization: this limited the
yearly caseload per trial center and affected the power of
the study with regard to the primary endpoints.
IMPROVE  is a multicenter “pragmatic” trial a
total of 613 patients with rAAA randomized to REVAR
or OR. REVAR was not associated with significant
reduction in either 30 day mortality or cost (“endovascular
strategy” 35.4 % vs OR 37.4 %; odds ratio 0.92; 95 %
confidence interval 0.66 to 1.28; P = 0.62). Only potential
advantages of REVAR were: (i) lower 30 day mortality in
the female population (P = 0.02) and (ii) earlier recovery
with direct discharge to home (189/201 (94 %) vs141/
183 (77 %); P < 0.001 %). Despite the considerable size
and the “real world” design of this study, the results
from the IMPROVE trial have to be considered carefully.
Among the 316 patients randomized to “endovascular
strategy”(mortality 35.4 %; 112/316) only less than half
were considered endoluminal candidate based on CTA
and actually underwent REVAR (30 day mortality 25 %;
38/150). The rest were either considered anatomically
unsuitable for REVAR and underwent OR (mortality
38 %; 43/112), died during conversion from REVAR to
OR (100 %; 4/4), died without treatment (mortality 94 %;
16/17) or didn’t have a confirmed rAAA (mortality 33 %;
11/33); this clearly influenced the overall 30 day
mortality of 35.4 % of the “endovascular” arm of the study.
Finally strategy decision and technical expertise, with only
a minimum of 5audited REVAR on the logbook, is
We conclude with a recommendation to transfer
patients with clinical suspect of rAAA to centers that can
offer both treatments with audited results.
Dr. BMTP, Dr. OC and Dr. FR contributed equally the same to this study and
all three certify that each had a “first author” role equally. Dr. BMTP has
written the section “vascular trauma: neck, chest and extremities”, Dr. OC has
written the section “abdominal vascular injury“ and Dr. FR has written the
section “ruptured aneurysms of the abdominal aorta: current management
and results”. All authors reviewed and approved the final manuscript.
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